Presentation on theme: "Weber Health Assessment in Nursing"— Presentation transcript:
1 Weber Health Assessment in Nursing Chapter 14: Assessing Skin, Hair, and Nails
2 Structure and Function of Skin The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration.Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.
3 Skin, Hair and NailsSkin- epidermis, dermis, subcutaneous layersHair- vellus, terminalNails- hard, transparent plates of keratinized epidermal cells
4 QuestionIs the following statement True or False?Sebum has some fungicidal and bactericidal effects.
5 AnswerTrue.Sebum has some fungicidal and bactericidal effects.
6 QuestionIs the following statement True or False?Asians and Native Americans have strong body odor.
7 AnswerFalse.Asians and Native Americans have mild to no body odor because of decreased sweat production. Caucasians and African Americans tend to have a strong body odor.
8 Skin CancerMost common of cancersThree types: melanoma, basal cell carcinoma, squamous cell carcinomaAsians are less susceptible
9 Risk Factors of Skin Cancer Sun exposureNonsolar sources of ultraviolet radiationMedical therapiesFamily history and genetic susceptibilityMolesPigmentation irregularitiesFair skin that burns and freckles easily; light hairAge
10 Risk Factors of Skin Cancer (Cont’d) Male genderChemical exposureHuman papillomavirusXerodrem pigmentosumLong-term skin inflammation or injuryAlcohol intake; smokingInadequate niacin in diet
11 Risk Reduction in Skin Cancer Reduce skin exposureAlways use sunscreen when sun exposure is anticipatedWear long-sleeve shirts and wide-brimmed hatsAvoid sunburnsUnderstand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancersHave annual skin cancer screenings
12 Risk Reduction in Skin Cancer Ensure diet is adequate in vitamin B3Examine the skin for suspected lesionsUse the ABCDE mnemonic to assess suspicious lesions:AsymmetryBorderColorDiameterElevation
13 QuestionWhich skin disorder may be caused by exposure to the sun?a. Acneb. Cancerc. Vitiligod. Warts
14 Answerb. Cancer.Rationale: Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure.
15 Cultural Variations in Skin Cancer Lowest rates: AsiansHighest rates: white AustraliansMost susceptible are people with pale white, freckled skin and red hair
16 Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Assess for hospital-acquired MRSA risk factors:Having an invasive medical deviceResiding in a long-term care facility
17 Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (cont.) Assess for community-acquired MRSA risk factors:Participating in contact sportsSharing personal items such as towels or razorsSuppression of the immune system function (e.g. HIV, cancer, or chemotherapy)Residing in unsanitary or crowded living conditions (dormitories or military barracks)
18 Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (cont.) Working in the health-care industryReceiving antibiotics within the past 3 to 6 monthsYoung or advanced ageMen having sex with men
19 Measures to Reduce Risk Factors Keep wounds covered.Do not share personal items.Avoid unsanitary or unsafe nail care practices.If treatment has been started, do not stop until recovery is complete.Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands.Clean sports equipment between uses to avoid spread of infection.
20 Nursing History: Present Health Concern Body odor problemsSkin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation)Changes in lesion appearanceFeeling changes (pain, pressure, itch, tingling)Hair loss or changesNail changes
21 Nursing History (cont.) Personal health historyFamily historyLifestyle and health practicesExposure to sun or chemicalsDaily care of skin, hairs, nailsUsual diet and exercise patterns
22 Client PreparationAsk the client to remove all clothing and jewelryHave the client sit comfortablyEnsure privacyMaintain comfortable room temperature
23 EquipmentGlovesExamination light and penlightMagnifying glassCentimeter rulerWood’s lightExamination gown or drape
24 Skin Assessment: Inspection Note any distinctive odorGeneralized color variationsSkin breakdownPrimary, secondary, or vascular lesions
25 Skin Assessment: Palpation LesionsTextureTemperature and moistureThickness of skinMobility and turgorEdema
26 Pressure Ulcer Risk Factors PerceptionMobilityMoistureNutritionFriction or shear against surfacesTissue tolerance decreased
27 Pressure Ulcer Risk Reduction Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document.Bathe with mild soap or other agent; limit friction; use warm not hot water; set bath schedule that is individualized.For dry skin: use moisturizers; avoid low humidity and cold air.Avoid vigorous massage.
28 Pressure Ulcer Reduction (cont.) Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point.Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient.Refer incontinence condition to primary care provider.Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.
29 Scalp and HairInspection and palpationGeneral color and condition, cleanliness, dryness or oiliness, parasites, and lesionsAmount and distribution of scalp, body, axillae, and pubic hair
30 Nail AssessmentNailsInspection: Nail grooming and cleanliness, nail color and markings, shape of nails,Palpation: Texture, assess texture and consistency, capillary refill
31 Nails Risk FactorsNails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspiration.Nail injury, trauma, or irritationImmune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications.Skin conditions such as psoriasis or lichen.Some trades or professionsContagion from one digit to another or one person to another.Possibly family predisposition.
32 Nails Risk Reduction Tips Wear leather shoes except for sports.Avoid wearing closed shoes all the time.Wear socks that wick away moisture.Avoid going barefoot in damp public areas.Avoid too much perspiration or water (wear gloves for hands).Avoid trauma to nails.Avoid unsanitary or unsafe nail care practicesIf treatment is started, do not stop until recovery is complete.
33 Physical Assessment (cont.) Capillary refillHair color and textureIndividuals of black American descent often have very dry scalps and dry, fragile hair.
34 Self-Assessment Skin, Hair, Nails Refer to Box 14.1 Self Assessment: How to Examine Your Own Skin
35 Normal and Abnormal Findings Share outcomes of assessment with peers
36 Pressure Ulcer Stages Stage One Stage Two Stage Three Stage Four Unstagable
37 Primary Skin Lesions Macule and Patch Papule and Plaque Nodule and TumorVesicle and BullaWhealPustuleCyst